Enrollment Application

• Montana Healthcare Programs Enrollment Application updated 02/2018

• Montana Healthcare Programs Enrollment Limited Enrollment Privileges: Ordering, Prescribing, and  Referring 02/2018

• Montana Healthcare Programs Enrollment Rendering 02/2018

Additional Owner/Manager Page

• Owner / Manager Additional Pages Needed

Individual Sections of Application

1. Cover Letter and Checklist

2. Disclosures, Screening, and Enrollment Requirements

3. Montana Healthcare Programs Provider Enrollment Application

4. Montana Healthcare Programs Agreement and Signature Page

5. License, CLIA, and Certification

6. Trading Partner Agreement

7. W-9 Form

8. Montana Healthcare Programs EFT and ERA Authorization Agreement

A form is required for each NPI requiring a change. Changes will be made to all files under that NPI. Do not send voided checks or deposit slips.

9. Passport and Team Care Agreement

10. CHIP Dental Provider Agreement and Signature

11. CHIP Provider Agreement and Signature for Extended Mental Health Benefits for Children with SED

12. Mental Health Services Plan Addendum

13. CSCT Services Contract

14. Exhibits: Statement of Work and Payment Schedule

Addendums and Other Enrollment Documents

72-Hour Presumptive Eligibility Program Provider Enrollment Addendum 08.2008

Electronic Billing Agreement (EBA)

Medicaid Provider Requirements
Provider requirements are located in Chapter 2 of the General Manual. To locate the General Manual, go to the home page of the provider website.  In the left menu, choose "Resources by Provider Type". Accept the End User Agreement, then choose your provider type from the alphabetical list.  Once you arrive at your provider type page the General Manual is listed at the top of the page.

 

What is the difference between enrolling as an individual and enrolling as an organization?

Only providers who are enrolled as an organization can bill for the services of other providers. Providers enrolled as individuals cannot bill for services rendered by another provider. Only providers enrolled as a clinic or with a clinic specialty can bill as a billing provider with another provider as the rendering/attending.

We have submitted all the required paperwork but still have not been notified that our enrollment is complete. How long do we wait before contacting Montana Provider Relations?

If you have not received your welcome letter 3 weeks after you have submitted all of your completed and signed paperwork, contact Montana Provider Relations at 1.800.624.3958 or 406.442.1837.

How do we know which taxonomy code to use for enrollment?

The confirmation letter or e-mail you received from NPPES will contain the taxonomy you use for enrollment. Taxonomy codes are listed on the website under the appropriate provider type. For billing purposes, use the taxonomy code noted in your welcome letter sent by Montana Provider Relations.

We were told to use clinic taxonomy. Do we use the one from Montana Provider Relations or do we get another one from NPPES?

Providers are not bound to use the taxonomy given to them by NPPES. For billing, providers use the taxonomy with which they enrolled in Montana Healthcare Programs. For clinic enrollment, providers choose from the drop-down list either the taxonomy that matches what they received from NPPES or the one that best fits their practice.

Where do we find ZIP+4 extensions?

You can find this information by typing in your address on the U.S. Postal Service website, http://zip4.usps.com/zip4/welcome.jsp.

How do we fill out the tax reporting information?

The tax reporting information is needed for generating 1099 tax information. Use the tax-reporting information from your W-9 to complete the tax-reporting section of the enrollment.

Are we required to fill out the ownership/control information?

Yes. CMS requires that ownership information be collected for all health care providers who provide services that are publicly funded so states can qualify for federal funds.

Refer to CFR 42 455.100–106. There is no distinction between for-profit and not for profit. Enrollments will be denied if ownership information is not provided.

How do we know if we are a provider-based facility?

Provider-based status means a relationship exists between a hospital as the main provider and one of the following as defined by rule:

• A provider-based entity is a health care provider “that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the name, ownership, administrative and financial control of the main provider.”

• A department of a provider is a “facility or organization or a physician office that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, financial and administrative control of the main provider.”

• A department cannot be licensed to provide health care services in its own right or be qualified on its own to participate in Medicare. The definition does not include a rural health clinic (RHC) or a federally qualified health center (FQHC) except in limited circumstances.

• A remote location of a hospital is defined as “a facility or organization that is either created by, or acquired by, a hospital that is a main provider for purposes of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider.” The remote location is not licensed in its own right or separately certified as a Medicare provider.

• A satellite facility is a hospital unit or part of a hospital unit that provides inpatient services in a building also used by another hospital or in one or more buildings on the same campus as buildings used by another hospital. Campus” is defined as the area immediately adjacent to the main buildings and other areas and buildings not strictly contiguous but that are located within 250 yards of the main buildings.

• All providers who are provider-based facilities are required to send the CMS letter received designating them as a provider-based facility.

Why are we required to sign up for electronic funds transfer (also referred to as direct deposit)?

Electronic funds transfer (EFT) makes funds available to you more quickly than paper checks. The electronic payment option allows Montana Health Care Programs providers to receive their payments on Monday of the payment week. If you feel you have extenuating circumstances that prohibit you from receiving payment via EFT, request a waiver by including a signed letter explaining why paper checks are required.

How will we know if our enrollment is complete?

Once your enrollment is complete, you receive a welcome letter from Montana Provider Relations informing you that your enrollment is active. The welcome letter contains your NPI for health care providers or your Atypical Provider Identifier (API) for atypical providers.